We Can Do Better Than Sanity

*** I don't usually do trigger warnings on this blog - But it goes without saying we're going to be talking about Mental Health (everything from anxiety to psychosis) and shitty representations thereof. So be forewarned if those are topics you don't have energy for right now.

People smarter than me have probably already eviscerated why "Sanity" mechanics range from problematic to outright toxic representations of mental health. But the question I want to explore today is why do we even call it "Sanity"? Is grappling with your own neurology (and often traumas) really what's at play here? I don't really think so. While the fear of loss of agency seems to be a principle factor, few games with Sanity mechanics are actually representing what it's like to work through mental health issues (from my experience with both Sanity mechanics and fairly serious mental health issues) [[*1]]. Rather, these mechanics are representing what it's like to fight a cosmic metaphysical influence that wraps its tentacles around your mind. Which is cool! But then why are we calling it Sanity?!?

[[From the 2018 Call of Cthulu video game - Just putting it out there, but this guy looks less like he's "Grappling with mental health issues" and more like he's "Being controlled and manipulated by cosmic influence" - Just a personal take. Seems less like a sanity thing more like a malevolent space bug thing.]]

CoC(k)

 Let's take the classic Call of Cthulu (CoC)... in it characters have Sanity as one of their most crucial stats. From the CoC wiki: "The loss of SAN [Sanity] points is the cost associated with gaining new but terrible knowledge of the Cthulhu Mythos. In this sense, SAN is a corruption of human behavior, morals, and personality. Thus, "Sanity" is the game’s register of the investigator’s mental resilience."

Loss of Sanity as a corruption of the self... a bit yikes, but it goes on to further clarify: "It is not designed to model or make light of real-world mental health conditions, in the same way that hit points (and the loss of them) in most RPGs do not make light of real-world physical trauma and injury." To which I must ask... then why hell are you calling it Sanity?? [[The answer is probably a mix of tradition, copyright and people not thinking twice about these sorts of things.]] And yes while a semantic argument can be made that definitionally all Sanity/Insanity measures is a "soundness of mind" (and thus a cosmic entity literally poisoning your mind to heed its specific instructions could be defined as a "loss of Sanity") that really doesn't feel like it holds up in common parlance. If a mind flayer eats part of your brain we don't really think of that as losing Sanity, we think of that as losing part of your brain.

Heck, even taken most literally, Sanity feels like a shortcut. A great deal of factors can trigger actual psychosis, and the struggles of mental health are so varied and nuanced that trying to hone them all down into just "Sanity" feels both lazy and sloppy. Which is to say nothing of the fact that the phenomena experienced in these games are often paranormal in nature, not as an actual result of psychosis.

You often lose SAN from seeing eldritch abominations (a cool disincentive to dissuade players from being "kill 'em all" action heroes and represent that most people would legitimately not want to fight the tentacle monsters). Loss of SAN can result in Involuntary Action [[re: Fear of loss of control]], including... Bouts of Madness[[*5]], adding a Phobia or Mania, the investigator's backstory being shifted, random "Delusions" - Etx. All of it does so love to raid the medical language around mental health to describe the cosmic horrors your character is going through. Which is both a rude slight against people with actual mental health issues and a gross disservice to genre that defines itself by things that exists outside of existing science. Trust me when I say the ways someone can help themselves when dealing with actual trauma versus the ways they can help themselves when terrorized by a cosmic entity are completely difference.

There's nothing irrational about feeling afraid of the horrible tentacle monster. [[*8]] In fact the people who are most likely to label you as "insane" (negative) are the ones who will write off your adventures as delusions. If this was the interplay (where more mythos knowledge ostracizes you from a hegemonic and judgmental society), that could actually be a really interesting metaphor for how one of the most awful parts of dealing with mental illness is the isolation and stigma you can face. Feeling like you alone are experiencing this horror, while the rest of the world simply dismisses you. But instead SAN is just a powder keg of (often non-sequitur) involuntary reactions caused by seeing a spooky monster.

Call of Cthulu's mechanics aren't bad as mechanics [[eg resource drains from seeing monster, causes loss of agency]], hell I'd even say they could interesting! It's interesting to watch my investigator recoil in horror at eldritch abominations and for that knowledge to forever change how they interface with the world. It's interesting to have my curiosity get the better of me and (after reading a cursed book) begin behaving erratically, behaving in ways modern medicine can't begin to describe or treat... but that's just the thing. Why are we using grounded terms and conditions that universally signal the mechanics being about one thing (mental health) when it's really about another (cosmic influence).

It'd be like having a spell in a fantasy setting that allows you to command another creature for 3d6 hours after which the creature must make a WIL check to not be Glamoured with you. And then calling this spell "Gaslight." Like what??? Why??? [[Admittedly in the context where you are a mage that has 3 abilities (Gaslight, Gatekeep and Girlboss) I'd maybe be willing to make an exception.]]

We can do better. We're writers after all!

Cosmic Influence

In the cult classic vide game (largely inspired by Call of Cthulu) Eternal Darkness you also lose Sanity when seeing enemy monsters. According to the manual in my hand "Sanity is a fragile thing! ... As your Sanity Meter drops, you may start to experience strange hallucinations, side effects of the madness that is slowly seizing your mind." Note: "Slowly seizing your mind." As per CoC rules, you lose Sanity from seeing spooky monsters. True to the mental health experience of many, by performing a finishing blow on an enemy you'll recover a bit of Sanity back. [[This is sarcasm - But it is how you recover Sanity in Eternal Darkness... sigh]]

[[An example of a Haunting from Silent Hill 4 - Suspiciously similar to some of the "Sanity" "Hallucinations" you often see in horror games that use Sanity as a measure of cosmic influence... where the visions actually tie in very directly to the in-lore supernatural elements at play... Almost like what they're dealing with has almost nothing to do with mental health... hmmm...]]

Now let's contrast this with another beloved horror game Silent Hill (we'll take Silent Hill 4 as the lead here). Protagonist Henry Townshed is trapped in his flat, barred by mysterious chains on the exit. His only escape is strange holes that appear around the apartment, teleporting him to dreamlike areas of Silent Hill full of unfathomable monsters. As the game progresses the apartment starts to... change... You'll walk into the room hear the moans of the dead, but on further investigation it was nothing. Did the walls move? Is that... flesh behind the couch? It's eerie, dreadful and actually tied to a mechanic behind the scenes! A mechanic that games like Eternal Darkness or Call of Cthulu might've called "Sanity" but which Silent Hill more aptly calls "Haunting." Because what's happening actually has nothing to do with Henry's mind, but rather the lore and supernatural entities surrounding him.

The problem here was never that games include whispers from beyond that only the protagonists can hear, visions of things untrue or even losing control of your behavior. The issue is that it ascribes these phenomena ((which are usually in-lore explicitly caused by paranormal means, often with legitimate paranormal effects)) to real world mental health terms and conditions ((without ever really exploring those conditions beyond a tropey stigmatized surface level understanding)). What's worse is they often paint these (now medicalized) conditions as irreversible and/or unmanageable. I'll grant that if an eldritch deity touches your mind, maybe that causes damage that is irreversible and unmanageable, because of some paranormal effect. But that's not really about your "Sanity" or actual Psychosis, that's about an outside entity influencing your reality.

And that's the real ticket - No matter which Silent Hill you play it's never about some "Sanity meter", it's about the town influencing you, and reflecting back what it sees and feels. Which is to say nothing of the fact that this opens up Silent Hill to actually play with themes of mental health (to varying degrees of success) whether that's in the erotic monster designs in Silent Hill 2 or how Silent Hill 3 features a protagonist haunted by guilt, alienation and the very real trauma of being born into a cult. But no matter which Mason is whacking flesh monsters with a golf club, the rusted reality of very real monsters is never about Sanity, it's about the Town and the people.

The terror lies in a (sometimes permanent) loss of agency and the monsters that are brought forth. The difference lies in what's taking away that agency. In Silent Hill the town itself pulls away your control over reality. Whereas in Eternal Darkness the framing is that the PCs are fighting their own mind that is "losing Sanity." But they never really are. They're fighting a cosmic entity with influence over their mind.

[[ Patch Notes!! It was luckily brought to my attention that this all kind of reads like I don't have a problem with the framing of psychosis as fail-state. I want to set the record straight that I emphatically do have a problem with Psychosis, Schizophrenia and various mental health issues framed as a Fail-State, or worse a point-of-no-return. Rather what I'm trying to say here is that what's at play isn't even Psychosis or Mental Health to begin with, they're just recklessly using these terms as shorthand. Psychosis as a Fail-State and Psychosis inappropriately portrayed as a boogie man to be feared in the same way one might have a legitimate fear of an eldritch deity could be its own article - Not to mention the alienation one faces when dealing with mental health issues ~ But for now you can check this footnote for more detailed thoughts after the article: [[*6]] ]] 

Doing Better

Consider; What makes for a better Cosmic Horror story? Grappling with mental health difficulties and slowly building tools to overcome them, or a cosmic entity scratching their finger nails across your mind in a way that may literally enslave you and will leave you understanding of reality forever changed by the truth? I'm of the opinion that the second one sounds much more like a Cthulu story, so why on earth are we trying to use the verbiage of that first one? Why not call "Sanity" "Cosmic Influence"? Wouldn't that be much more descriptive and flavorful?

Back to CoC, mechanically the idea that you have a Stat [[let's call it Influence INF]] that represents Eldritch Knowledge, that accumulates as you learn more incongruous things is really cool. Looking at impossible geometry should do something to your character, seeing in 4 dimensions briefly would shift your mind. Hell, you could even call the stat Shift as your character gains the new perspective. Or maybe Insight... I love how BloodBorne handled this. Or maybe it's a Stat that counts down, but instead of Sanity it's Ignorance. As the truth of the universe unfolds itself, so too does the reality around you unfold, not as manifested by mental illness but as manifested by seeing the honest-to-goodness reality of the world you never saw before.

Gaining more and more INF means you have less and less control over what your PC does and perceives. Also sounds fun! Gaining INF can result in uncontrollable actions, your backstory and memories literally shifting and rewriting, things hidden behind the 4th dimension reveal themselves, the true shapes of your adversaries become clear, even your character rolling disadvantage or having permanent aversions to a thing as the last human parts of them desperately fight back, or worse the cosmic plants seeds of control. All of this works, without needlessly hijacking the language of mental health.

You can do this outside the supernatural too! Gradient Descent has a Stat called the Bends which represents both the Player and PCs' inability to discern who is and isn't a replicant. Instead of simply calling the Bends "Paranoia" it specifically gets at how the situation you're in is Bending your perception of what could and couldn't be true. How being stuck in this horrible place and horrible situation is bending your affirmative knowledge of what is and isn't real. In the same way Among Us doesn't need a paranoia stat to instill fear and suspicion, neither did Gradient Descent.

Bonus points because certain Bends rolls can later reveal that a PC actually is an android and was replaced at some point, one of the most heart stopping revelations I've seen in random rolling (in no small part because of the amazing build up). [[The Bends is also a clever nod to Decompression Sickness to fit the nautical themes present. I say nod because obviously Decompression Sickness has almost nothing to do with knowledge of self or being a surprise android.]]

The Awkward Middle Ground

Panic is a very real thing. You don't need to have anxiety disorders to be so stressed you accidentally explode at someone. You don't need chronic depression to feel hopeless and unable motivate yourself to move forward. And I say this as someone who suffers from bouts of both. Having bad reactions to bad days is a very real, very universal thing and horror generally involves people having very bad days.

[[Patch Notes!! I'm about to talk about Mothership and some issues I have with it... Or better to say some issues I have with the 0th Edition! See the great thing about TTRPGs and having so many things delivered by PDFs is that this stuff is pretty easy to fix. It was brought to my attention that Mothership is doing exactly that with its 1st Edition (which I haven't read yet XT) - But I'm glad to see writers are taking these things into consideration and adjusting their work to be more empathetic!]]

While Mothership's "Sanity" save really could just be a "Calm" or "Cool" save, the idea of slowly filling a Stress bar that bubbles into a Panic check really works in my opinion! To me Stress and Panic (while important factors of mental health) are such universal experiences (like Hunger and Wounds) that handling it in this way actually resonated quite a bit. [[*1]] What did not resonate was the Panic Effects. Some are spectacular and really get at the human condition in a scenario that's going to shit; Overwhelmed (Gain even more Stress), Rattled (roll with Disadvantage for 2d10 minutes), and even Cowardice to a lesser extent (make Fear checks to engage in Combat - maybe would've renamed to "Flight" because Cowardice can have all kinds of connotations) feel like good examples. 

Others... Ugh.... Broken[[*3]] is as offensive as it is mechanically inexpressive (Panic whenever a nearby Crewmate fails a save... They literally could've just called it Hopeless or Despair or something). Psychological Collapse just labels the character as "irreparably insane" and thus unplayable to all but the Warden, and frankly if you want to have a scenario where someone turns traitor as a result of Panic just do that instead of making it about this Pseudo-Psychology.[[*4]] Speaking of, "Psychotic" may be the worst offender as it has you specifically attack a nearby crewmate. Not "Itchy Trigger Finger", not "Misfire", not "Snap Reflexes"... "Psychotic". I unironically wonder if any of these writers have known someone with Psychosis or know what that word means.

It's difficult enough for people who experience psychosis (or are on anti-psychotics etc) to explain to people that "Psychotic" doesn't instantly mean "Violent crazed threat to everyone" and reading stuff like this is just UGH. WHY. It serves no benefit but to reinforce harmful stereotypes for the sake of "tropes" instead of using already existing and flavorfully more descriptive language for a thing. [[So I'm very very glad they're changing it in Mothership 1e]]

[[In Haunting Ground you can enter a Panic Mode - From my own experiences with severe panic episodes, it looks nothing like this. However something about the feel, gets at me. The way time feels like it's moving too slow and too fast. The way my surroundings melt away and all the lights feel too bright and the darkness feels too dark...]]

This is more than a slap on the wrist to these writers for being actively negligent in regards to representing mental health and arguably causing harm. This is a call out for being lazy writers who are doing a disservice to their own prose. If you want to have your fun little horror game to focus on verbs like Panic (ex: panic spirals) and and build mechanics where everyone is acting unpredictably, then awesome! If you want to build your dark descent dungeon crawl where the walls themselves paranormally start to whisper the deeper you delve, and mechanics are forcing Players to question who and what to trust, that sounds rad! If you want the act of simply seeing monster to literally rob the PCs of a degree of control and slowly chip away at their resources and autonomy, I can dig that! These are cool mechanics, especially a horror game! But these aren't really mechanics about mental health or psychosis or sanity, especially as they're often executed and themed. So stop trying to make it about that and write what you mean! [[*2]]

FURTHER READING

Psychosis is Badly Written in Tabletop

[[*1 : As a personal aside it feels important to be upfront that I've been diagnosed BPD and chronic depression by two different therapists and my last one felt confident that I probably have an anxiety disorder. While on my worst days I scratch my face bloody [[literally happened this week and I had to go to work covered in long scabs RIP]], I'm generally Making It Work. Fighting my own brain and emotional chemistry can be scary, but I'm lucky enough to have built a solid tool box to Get Through It. I don't really think my lived experience makes me any kind of expert or authority here, nor do I think I have the definitive experience of mental illness, as it can permutate and present in nearly infinitesimal ways. But I'd like to think it gives me a degree of insight and reflection on the matter, especially in how I see these conditions stigmatized by people who have never known better. Certainly between that and having a variety of friends with mental health issues and yes, even psychosis, it's felt like enough to know when a writer is totally out of touch with this.]]

[[*2 : So the phrase "Write what you mean" is incredibly good faith. I like to assume the best in everyone, that many of these writers don't actually think of people with psychosis as crazed violent animals, but rather as real people. They just use Psychosis because it's easy and tropey and what they're used to using without thinking. There are, of course, going to be those writers who do absolutely know what they're doing when they do this and are intentionally painting a picture of mental illness in the coldest and most othering light. Who see people with mental illness as a kind of unknown threat and probably fear them as much as they fear suffering from psychosis. To those writers instead of "write what you mean" I'd prefer to say "you need to get out there more and actually talk to people. Open up your empathy, you'll be surprised by what you can learn about yourself and others" ]]

[[*3 : Funnily enough this whole thing got started when I heard about Nibiru handling the "descent into madness" trope as Becoming Broken... and like ugh. I don't get what goes through peoples' heads when they equate mental health and trauma to a slow and irreparable erosion instead of a process, an ebb and flow of clarity and exhaustion.]]

[[ *4 : To my awareness there's no such thing as a Psychological Collapse. Mental Breakdowns are sort of a real thing, but aren't a proper term. Speaking from experience a breakdown can absolutely suck ass. I've lost days out of my life and lost control over my actions in some pretty sucky and horrifying ways. But I can tell you with full assurance that a breakdown is not a one-way road.]]

[[*5 : I actively avoid using the word Madness in here cause I'm of a few minds of it. It's outdated, but in a way that's almost taken on a meaning of its own. This is kind of half baked, and maybe this is just my own personal attachment to the word, but I'm way less suss of someone who describes a cultist as "Mad" than as "Insane" - even if by some definitions they're really causing the same damage. Again of two minds about it, so I'm generally avoiding it here. I think maybe this comes from an understanding and fondness for the spiritual process of Divine Madness...]] 

[[*6 : To me what is often described in cosmic horror simply isn't psychosis (despite it using that language). There's a difference between an actual condition where you can hear voices (which, to be clear, should not be something to be feared or reviled), and a scenario where a separate malevolent cosmic entity is speaking to you using your own voice in your own head and can potentially control you via magic (which, yeah, I do think that's something worth being scared of). The prior is a legitimate health condition that's manageable, the latter is a malicious supernatural force that you're fighting in-fiction.

Additionally I didn't really do a good job of hammering home how actually grappling with mental health is not some direct dissent into madness, nor some complete loss of agency to be feared. While something like "knowledge of the 4th dimension" is something (which is IMO fun) to be tracked on a bar, or even something like "demonic possession" these are things totally separate from mental health, and both the verbiage and execution need to reflect that. High Insight in BloodBorne has you seeing extra eyes on everything as you experience the true world - This is both more flavorful, interesting and true to the source material of cosmic horror than saying "Your investigator saw an eyeball monster, you are now schizophrenic and can see eyeballs on everything" as though schizophrenia is a fail-state and also as if the eyeballs on everything aren't actually there. 

Mental Illness (a term I feel more comfortable ascribing to myself) is something that (in my experience as someone with BPD) sucks to deal with sometimes but it's absolutely manageable, and there's some good days and bad. I would not say the bad days are a "desirable" outcome, and especially not when they cause harm to others (because causing harm to others is one of my personal fail-states[[*8]]). But I wouldn't say I "fear" the bad days in the same ways that one might "fear" a cosmic horror. One is a reality that I've built a toolbox to work around, can be communicated to others and doesn't make me any less human, while the other is a tentacle monster that wants to eat my brains and controls the 4th dimension - They're non-sequitur experiences, which is kind of my whole thesis.

As someone who has done a not insignificant amount of things that I regret as a result of my own mental illness, gamifying making bad snap decisions actually kind of appeals to me as something that could be interesting (within reason and if handled delicately and empathetically). And mechanics like Stress that ebb and flow, and in my own real life experience is a thing I try to keep low feel interesting! But that's not really what's happening in the context of seeing a spooky monster and then functionally getting glamoured. 

More over as someone who has experienced only a handful of what I'm told are psychotic episodes, I don't assume to be an expert on that matter. This is just one viewpoint. To me there is a meaningful difference between a literal ghost that has literal lore literally controlling your emotions for its own gain ((which doesn't make you any less human, but is something you can and should fight in most instances)), versus the ebb and flow of (in my case) working with a disorder that disconnects me from myself and brings me to places I'd often not like to be ((which similarly doesn't make me less human or "crazy" (negative), but doesn't really exist as something "other" to eradicate, but rather something to work with and be conscious of)). 

The way media makes us fear Psychosis and those suffering from Mental Illness (in a most dehumanizing way) does more damages than I can frankly list here, so above all I think it's best to avoid reinforcing that fear. This is all a bit scattered because the thesis of this article was never "How can we handle Psychosis and Sanity better" and more "Neither of these were topics being dealt with anyway in cosmic horror so why are we recklessly using improper language that could reinforce negative stereotypes".]]

[[ *7 : So this gets a bit messy, but when I say Fail-State here understand that I don't mean point-of-no-return fail-state. I just mean it's an undesirable outcome that can (and has) happened as a result of my mental health issues. But similarly there's a line between hurting someone and the slasher-villain stereotype of psychosis often depicted in Horror ]]

[[ *8 : To any who take issue with me using "irrational" ((because the term can sometimes be used against those with mental health issues in some not great ways)) - Understand that when I say it I'm thinking in terms of  "If I'm having an anxiety attack (which I've experienced on multiple occasions), I see that as "irrational" because my body isn't really operating on reason. Meanwhile if I am in a life or death situation and feeling panicked that is incredibly rational." -- Most mental health professionals I've worked with use terms like "irrational" to help me work through what I should and shouldn't be worried about, so it's second nature for me to divide up perceived threats as such.]]